Results from a large-scale epidemiologic look-back investigation of improperly reprocessed endoscopy equipment

Infection Control and Hospital Epidemiology

Volumn 33, Issue 7, 2012, Pages 649-656

  Holodniy, Mark ^a,b,e   Oda, Gina ^a   Schirmer, Patricia L ^a   Lucero, Cynthia A ^a   Khudyakov, Yury E ^c   Xia, Guoliang ^c   Lin, Yulin ^c   Valdiserri, Ronald ^d   Duncan, William E ^a   Davey, Victoria J ^a   Cross, Gerald M ^a  

^a DEPARTMENT OF VETERANS AFFAIRS   (United States)

^b STANFORD UNIVERSITY SCHOOL OF MEDICINE   (United States)

^c CENTERS FOR DISEASE CONTROL AND PREVENTION   (United States)

^d U S DEPARTMENT OF HEALTH AND HUMAN SERVICES   (United States)

^e Office of Public Health Surveillance and Research   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

HEPATITIS B ANTIBODY; HEPATITIS B SURFACE ANTIGEN; HEPATITIS C ANTIBODY; HUMAN IMMUNODEFICIENCY VIRUS ANTIBODY;

ADULT; AGED; ARTICLE; BLOODBORNE BACTERIUM; COHORT ANALYSIS; COLONOSCOPE; COLONOSCOPY; DEVICE INFECTION; DISINFECTION; ELECTRONIC MEDICAL RECORD; ENDOSCOPE; ENDOSCOPY; FEMALE; GENETIC DISTANCE; GENETIC SCREENING; HEPATITIS B VIRUS; HEPATITIS C VIRUS; HUMAN; HUMAN IMMUNODEFICIENCY VIRUS; INFECTION RISK; INSTRUMENT STERILIZATION; LARYNGOSCOPE; LARYNGOSCOPY; MAJOR CLINICAL STUDY; MALE; RETROSPECTIVE STUDY; SEROPREVALENCE; VETERANS HEALTH; VIRUS INFECTION; VIRUS TRANSMISSION;

ADULT; AGED; AGED, 80 AND OVER; CROSS INFECTION; ELECTRONIC HEALTH RECORDS; ENDOSCOPES; EPIDEMIOLOGIC STUDIES; EQUIPMENT CONTAMINATION; EQUIPMENT REUSE; FEMALE; HEPACIVIRUS; HEPATITIS B VIRUS; HIV; HIV SEROPREVALENCE; HUMANS; MALE; MEDICAL AUDIT; MIDDLE AGED; VIREMIA;

EID: 84863201841     PISSN: 0899823X     EISSN: None     Source Type: Journal    
DOI: 10.1086/666345     Document Type: Article

References (39)

1. Seoane-Vazquez E, Rodriguez-Monguio R. Endoscopy-related infection: relic of the past? Curr Opin Infect Dis 2008;21(4): 362-366.
2. Srinivasan A. Epidemiology and prevention of infections related to endoscopy. Curr Infect Dis Rep 2003;5(6):467-472.
3. Rutala WA, Weber DJ. Reprocessing endoscopes: United States perspective. J Hosp Infect 2004;56(suppl 2):S27-S39.
4. Spach DH, Silverstein FE, Stamm WE. Transmission of infection by gastrointestinal endoscopy and bronchoscopy. Ann Intern Med 1993;118(2):117-128.
5. Rutala W, Weber D, Committee THICPA. Guideline for Disinfection and Sterilization in Healthcare Facilities. Atlanta: Centers for Disease Control and Prevention, 2008.
6. Seoane-Vazquez E, Rodriguez-Monguio R, Visaria J, Carlson A. Endoscopy-related infections and toxic reactions: an international comparison. Endoscopy 2007;39(8):742-778.
7. Morris J, Duckworth GJ, Ridgway GL. Gastrointestinal endoscopy decontamination failure and the risk of transmission of blood-borne viruses: a review. J Hosp Infect 2006;63(1):1-13.
8. Alvarado CJ, Reichelderfer M; Association for Professionals in Infection Control. APIC guideline for infection prevention and control in flexible endoscopy. Am J Infect Control 2000;28(2): 138-155.
9. Banerjee S, Shen B, Nelson D, et al. Infection control during GI endoscopy. Gastrointest Endosc 2008;67(6):781-790.
10. Ishino Y, Ido K, Koiwai H, Sugano K. Pitfalls in endoscope reprocessing: brushing of air and water channels is mandatory for high-level disinfection. Gastrointest Endosc 2001;53(2): 165-168.
11. Cleaning and disinfection of equipment for gastrointestinal flexible endoscopy: interim recommendations of a Working Party of the British Society of Gastroenterology. Gut 1988;29(8): 1134-1151.
12. Cleaning and disinfection of equipment for gastrointestinal endoscopy: report of a Working Party of the British Society of Gastroenterology Endoscopy Committee. Gut 1998;42(4): 585-593.
13. Nelson D, Jarvis W, Rutala W, et al. Multi-society guideline for reprocessing flexible gastrointestinal endoscopes. Infect Control Hosp Epidemiol 2003;24(7):532-537.
14. Ayliffe G. Decontamination of minimally invasive surgical endoscopes and accessories. J Hosp Infect 2000;45(4):263-277.
15. Banerjee S, Nelson D, Dominitz J, et al. Reprocessing failure. Gastrointest Endosc 2007;66(5):869-871.
16. Foweraker JE. The laryngoscope as a potential source of crossinfection. J Hosp Infect 1995;29(4):315-316.
17. Yee KF. Decontamination issues and perceived reliability of the laryngoscope-a clinician's perspective. Anaesth Intensive Care 2003;31(6):658-662.
18. Lubbe D, Fagan J. South African survey on disinfection techniques for the flexible nasopharyngoscope. J Laryngol Otol 2003; 117(10):811-814.
19. Muscarella L. Prevention of disease transmission during flexible laryngoscopy. Am J Infect Control 2007;35(8):536-544.
20. Sooy CD, Gerberding JL, Kaplan MJ. The risk for otolaryngologists who treat patients with AIDS and AIDS virus infection: report of an in-process study. Laryngoscope 1987;97(4):430-434.
21. Bond WW, Favero MS, Petersen NJ, Ebert JW. Inactivation of hepatitis B virus by intermediate-to-high-level disinfectant chemicals. J Clin Microbiol 1983;18(3):535-538.
22. Hanson PJ, Gor D, Jeffries DJ, Collins JV. Elimination of high titre HIV from fibreoptic endoscopes. Gut 1990;31(6):657-659.
23. Hanson PJ, Gor D, Clarke JR, et al. Contamination of endoscopes used in AIDS patients. Lancet 1989;2(8654):86-88.
24. Classen M, Dancygier H, Grtler L, Deinhardt F. Risk of transmitting HIV by endoscopes. Endoscopy 1988;20(3):128.
25. Chanzy B, Duc-Bin DL, Rousset B, et al. Effectiveness of a manual disinfection procedure in eliminating hepatitis C virus from experimentally contaminated endoscopes. Gastrointest Endosc 1999;50(2):147-151.
26. Nelson D. Effectiveness of manual cleaning and disinfection for the elimination of hepatitis C virus from GI endoscopes. Am J Gastroenterol 2002;97(1):204-206.
27. Ramachandran S, Xia G-L, Ganova-Raeva L, Nainan O, Khudyakov Y. End-point limiting-dilution real-time PCR assay for evaluation of hepatitis C virus quasispecies in serum: performance under optimal and suboptimal conditions. J Virol Methods 2008;151(2):217-224.
28. Nainan O, Alter M, Kruszon-Moran D, et al. Hepatitis C virus genotypes and viral concentrations in participants of a general population survey in the United States. Gastroenterology 2006; 131(2):478-484.
29. Patel P, Larson AK, Castel A, et al. Hepatitis C virus infections from a contaminated radiopharmaceutical used in myocardial perfusion studies. JAMA 2006;296(16):2005-2011.
30. Cody S, Nainan O, Garfein R, et al. Hepatitis C virus transmission from an anesthesiologist to a patient. Arch Intern Med 2002;162(3):345-350.
31. Thompson ND, Hellinger WC, Kay RS, et al. Healthcareassociated hepatitis C virus transmission among patients in an abdominal organ transplant center. Transpl Infect Dis 2009;11(4): 324-329.
32. Rutala W, Weber D. How to assess risk of disease transmission to patients when there is a failure to follow recommended disinfection and sterilization guidelines. Infect Control Hosp Epidemiol 2007;28(2):146-155.
33. Backus L, Gavrilov S, Loomis T, et al. Clinical case registries: simultaneous local and national disease registries for population quality management. J Am Med Inform Assoc 2009;16(6): 775-783.
34. Schembre DB. Infectious complications associated with gastrointestinal endoscopy. Gastrointest Endosc Clin N Am 2000;10(2): 215-232.
35. Cheung RJ, Ortiz D, DiMarino AJ. GI endoscopic reprocessing practices in the United States. Gastrointest Endosc 1999;50(3): 362-368.
36. Kaczmarek RG, Moore RM, McCrohan J, et al. Multi-state investigation of the actual disinfection/sterilization of endoscopes in health care facilities. Am J Med 1992;92(3):257-261.
37. Gorse GJ, Messner RL. Infection control practices in gastrointestinal endoscopy in the United States: a national survey. Infect Control Hosp Epidemiol 1991;12(5):289-296.
38. Rutala WA, Clontz EP, Weber DJ, Hoffmann KK. Disinfection practices for endoscopes and other semicritical items. Infect Control Hosp Epidemiol 1991;12(5):282-288.
39. Lessa F, Tak S, Devader S, et al. Risk of infections associated with improperly reprocessed transrectal ultrasound-guided prostate biopsy equipment. Infect Control Hosp Epidemiol 2008; 29(4):289-293.